Pediatric Autoimmune Encephalitis Following COVID-19 Infection

Similar to the pathogenesis of autoimmune disease, SARS-CoV-2 (COVID-19) infection has been shown to be associated with dysregulated and persistent inflammatory reactions and production of some antibodies. We report 3 pediatric patients found to have serum SARS-CoV-2 antibodies who presented with neurologic findings suggestive of postinfectious autoimmune-mediated encephalitis. All 3 cases showed lymphocytic pleocytosis on cerebrospinal fluid studies and marked improvement in neurologic symptoms after high-dose intravenous corticosteroids. The manifestations of SARS-CoV-2 infection in the pediatric population are still an evolving area of study, and these cases suggest autoimmune-mediated encephalitis as yet another SARS-CoV-2 related complication.

Total Wrist Fusion with an Intramedullary Device: A Single-Institution Series with a Minimum of One Year Follow-Up

Objective The primary purpose of this study was to evaluate the functional and surgical outcomes of total wrist fusion (TWF) following the use of a locked intramedullary nail (IMN). Methods A single institution study was performed, which entailed in-person reexamination of 18 patients (n = 19 wrists), out of 35 eligible patients, who underwent TWF with an IMN from 2010 to 2017. For each patient, demographic, preoperative diagnosis, physical examination, wrist radiograph, and outcome questionnaire data were obtained. The questionnaires included the visual analog scale (VAS), quick disabilities of the arm, shoulder, and hand (QuickDASH), and Mayo Wrist Score assessments. In addition, complication and reoperation data for all TWFs with an IMN during the 2010 to 2017 period (35 patients, n I = 38 wrists) were noted. Results In the 18 patients, age was 47.6 ± 13.9 years, 12 (63.2%) were female, and median follow-up was 150 weeks (range: 74–294). The VAS score was 0 ± 0 in 5 of 19 wrists with rheumatoid arthritis (RA) and 1.82 ± 2.78 in 14 of 19 wrists without RA. It was found that 21 of 38 wrists (55.3%) had an implant-related complication and 5 wrists (13%) underwent a reoperation due to the implant itself. Conclusions To date, no sufficient data are present demonstrating a clear advantage of an IMN over dorsal plating for TWF at intermediate-term follow-up. Surgeons should be knowledgeable of the several potential complications of this IMN prior to its use for TWF. Level of Evidence This is a Level IV, therapeutic study.

The Wnt Signaling Pathway in Diabetic Nephropathy

Diabetic nephropathy (DN) is a serious kidney-related complication of both type 1 and type 2 diabetes mellitus (T1DM, T2DM) and the second major cause of end-stage kidney disease. DN can lead to hypertension, edema, and proteinuria. In some cases, DN can even progress to kidney failure, a life-threatening condition. The precise etiology and pathogenesis of DN remain unknown, although multiple factors are believed to be involved. The main pathological manifestations of DN include mesangial expansion, thickening of the glomerular basement membrane, and podocyte injury. Eventually, these pathological manifestations will lead to glomerulosclerosis, thus affecting renal function. There is an urgent need to develop new strategies for the prevention and treatment of DN. Existing evidence shows that the Wnt signaling cascade plays a key role in regulating the development of DN. Previous studies focused on the role of the Wnt canonical signaling pathway in DN. Subsequently, accumulated evidence on the mechanism of the Wnt non-canonical signaling indicated that Wnt/Ca2+ and Wnt/PCP also have essential roles in the progression of DN. In this review, we summarize the specific mechanisms of Wnt signaling in the occurrence and development of DN in podocyte injury, mesangial cell injury, and renal fibrosis. Also, to elucidate the significance of the Wnt canonical pathway in the process of DN, we uncovered evidence supporting that both Wnt/PCP and Wnt/Ca2+ signaling are critical for DN development.

Outcomes of Tunneled Dialysis Catheter In Hemodialysis Patients In A Tertiary Care Hospital

BACKGROUND: To evaluate tunnel dialysis catheter (TDC) patency and its outcome among patients receiving TDC in a tertiary care hospital.METHODS: Retrospectively patients’ records were reviewed who underwent TDC placement during February 2016 to November 2020 at Department of Interventional Radiology, Liaquat National Hospital, Karachi, Pakistan. Patients’ age, gender, residence, comorbidity, catheter placement site, use of antibiotics before catheter insertion, reasons for catheter removal and total catheter days were retrieved from patients’ medical record file.RESULTS: 130 patients received TDC with a median follow-up of 148 (inter-quartile range: 60.8 – 274.3) days. 94(72.3%) catheters were electively removed whereas 18(13.8%), 16(12.3%) and 2(1.5%) catheters were removed due to infections, blockage and physical damage respectively. None of the mortality was observed due to catheter related complication. The incidence of overall infection, bacteremia and other infections during one year was 7.3, 5.01 and 3.19 per 10,000 patient-days respectively. Infection free survival rate was 68% with mean time to infection was 676.63 (95% CI: 593.87 – 759.39) days. During the study, total catheter patency was 53.2%. None of the patients’ characteristics was associated with catheter related infections and catheter patency.CONCLUSION: TDCs are the best available alternative for short to intermediate term use for hemodialysis when all preventive measures are taken to avoid catheter related complications either infectious or non-infectious until permanent dialysis access is achieved or renal transplant is done. It may also serve as long term hemodialysis mode in patients in whom permanent access or transplant is not preferred.

Factors Affecting Utilization of Antenatal Care Services Among Women Visiting for Institutional Delivery in Tertiary Hospital, Bhairahawa, Nepal: A Cross Sectional Study

INTRODUCTION: Antenatal Care (ANC) services utilization during pregnancy plays an important role in prevention and management of pregnancy related complication thus improving the maternal and child health. Hence this study aimed to identify the factors influencing utilization of ANC service among women visiting for institutional delivery in tertiary hospital of Bhairahawa, Nepal. MATERIAL AND METHODS: Hospital based cross-sectional study was carried among 396 women admitted in the postnatal ward of Universal College of Medical Sciences and Teaching Hospital, Bhairahawa, Nepal form September 2019 to December 2019 following ethical clearance and verbal consent from participants. Variables with significant association (p<0.05) in bivariate analysis were entered into multivariate logistic regressions to find the factors affecting utilization of antenatal care services. RESULTS: This study revealed that 18.43% of respondents did not receive any ANC services. Among those who were not receiving ANC service, 86.3% never felt the need for ANC services throughout the period of pregnancy. ANC service utilization was found to be associated with religion (AOR=3.15, 95% CI: 1.40-7.08) and husband education (AOR=5.09, 95% CI: 1.63-15.92). CONCLUSION: In spite of being an essential component for the care of pregnant women ANC services was not utilized by all of them as many of them did not felt the need of this service. Thus it is recommended to increase awareness regarding the available services and its importance by local stakeholders to prevent further morbidity and mortality.

Antibiotic use in nasal bone fracture: a single-center retrospective study

Background: Prophylactic antibiotics are used to prevent surgical wound infection; however, proper indications must be followed with careful consideration of the risks and benefits, especially in clean or clean-contaminated wounds. Nasal bone fractures are the most common type of facial bone fracture. The most common method for treating nasal bone fracture is closed reduction, which is performed inside the nasal cavity without an incision. The purpose of this study was to determine the need for antibiotic use in the closed reduction of nasal bone fractures.Methods: A retrospective study was conducted using data from the National Insurance Service Ilsan Hospital of the Republic of Korea between 2016 and 2018. The records of patients who underwent closed reduction of nasal bone fracture were reviewed and classified according to sex, age, comorbidities, perioperative antibiotic usage, postoperative complications, nasal packing, anesthesia type, surgeon’s specialty, and operation time.Results: Among the 373 patients studied, the antibiotic prescription rate was 67.3%. Just 0.8% of patients were prescribed preoperative antibiotics only, 44.0% were prescribed postoperative antibiotics only, and 22.5% were prescribed both preoperative and postoperative antibiotics. There were no cases that satisfied the definition of “surgical site infection.” Furthermore, 2.1% of infection-related complications (e.g., mucosal swelling, synechia, and anosmia) occurred only in the antibiotic usage group. The use of nasal packing, anesthesia type, and surgeon’s specialty did not show any difference in infection-related complication rates.Conclusion: According to the study findings, the routine use of perioperative antibiotics is not recommended in uncomplicated nasal bone fracture surgery.

Peritoneal Dialysis Associated Peritonitis Rate – Validation of a Simplified Formula

Peritonitis is the most important therapy-related complication of peritoneal dialysis (PD). Unfortunately, many PD centers around the world do not accurately record peritonitis rate, mainly because they cannot ascertain PD patient time-at-risk from “patient flow” data - that is, calculating PD patient-days from dates when patients start and finish PD. We propose a simplified method of calculating PD peritonitis rate using PD patient time-at-risk from “patient stock” data - - that is, calculating PD patient-days from the number of prevalent PD patients at the center at the start of the year and the corresponding number at the end. We compared gold-standard measurements of annual PD peritonitis rates with simplified ones in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) / New Zealand (NZ) PD Registry, and Le Registre de Dialyse Péritonéale de Langue Française et hémodialyse à domicile (the RDPLF). A total of 268 centers from 9 countries with 4311 center-years and 110,185 patient-years of follow-up were modelled. Overall agreement was excellent with a concordance correlation coefficient of 0.978 (95% confidence interval [CI] 0.975-0.980) in ANZDATA / NZ PD Registry, and 0.978 (0.977-0.980) in the RDPLF. There was statistically significant lower agreement for smaller centers in the registries at 0.972 (0.966-0.976) and 0.973 (0.970-0.976) respectively, although the performance of the simplified formula remains clinically sound in even these centers. The simplified method of calculating PD peritonitis rate is accurate, and will allow more centers around the world to measure, report, and work on reducing PD peritonitis rates.

Impact of Pharmacy Services on Time to Elexacaftor-Tezacaftor-Ivacaftor Initiation

The approval of elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA) expanded highly effective cystic fibrosis transmembrane receptor modulator therapy to approximately 90% of persons age 12 and older with cystic fibrosis. Clinical pharmacists and pharmacy technicians played a key role in planning for ELX/TEZ/IVA initiation prior to FDA approval as well as initiating therapy after approval. This study evaluates the impact of pharmacy services on time to ELX/TEZ/IVA initiation. A retrospective chart review evaluated patients qualifying for ELX/TEZ/IVA at a single health system between October 21, 2019 and April 1, 2020. Patients filling ELX/TEZ/IVA at an integrated health system specialty pharmacy (HSSP) versus an outside specialty pharmacy (SP) started on therapy an average of 10.8 days faster (10.8 days ± 14.0 vs 21.6 days ± 18.8 respectively; p=0.006). More patients filling at a HSSP received ELX/TEZ/IVA within 14 days of the prescription being written compared to outside SPs (82.0% vs 41.4% respectively; p=0.001). Pre-ELX/TEZ/IVA initiation, patients were hospitalized for a CF related complication for an average of 6.26 days (range 0-183) compared to 1.16 days (range 0-91) post-ELX/TEZ/IVA initiation. Lastly, an estimated $134,810 was saved in the 105 patients that were able to fill ELX/TEZ/IVA at a HSSP by initiating drug an average of 10.8 days quicker than outside SPs. The results of this study demonstrate the value of an integrated HSSP model. Further advocacy for inclusion of integrated HSSPs by pharmacy benefit managers is needed to optimize medication access, control costs, and improve patient outcomes for patients receiving care within a health system.

Limberg flap as a Primary Treatment for Pilonidal Sinus at Nepal Mediciti Hospital: A Single Unit Experience

INTRODUCTION: Pilonidal Sinus is a common condition with estimated incidence of 260 per million population with more male predilection and is often seen in sacrococcygeal area but has also been described in other areas with hair. The Limberg rhomboid flap was designed by Limberg in 1946 for the closure of a sixty degree rhombus shaped defect with a transposition flap. We would like to share our single unit experience of Rhomboid Limberg flap for Pilonidal sinus in our hospital. METHODS: This is an ongoing prospective descriptive study in the Department of General Surgery and Digestive Diseases of Nepal Mediciti Hospital from October 2018. The demographic of the patients, presenting symptoms, duration of symptoms and previous interventions are recorded and the Rhomboid Limberg flap surgery is done under regional or general anesthesia in prone position. The patient is given intravenous antibiotic and is instructed to sleep laterally or in prone position for 24 hours. The dressing is removed and the wound is inspected for flap status in the next morning. The patient is discharged on 1st post-operative day on oral antibiotics for 7 days and is followed on 7th post-operative day for removal of suction drain and alternate sutures in the skin and remaining sutures are removed on 10th post-operative day. RESULTS: We have done 28 cases of Limberg flap for Pilonidal Sinus from October 2018 to December 2020 of which 24 were male patients. None of our patients had flap necrosis. One patient presented with accidental removal of suction drain on 5th postoperative day, however he didn’t develop any wound related complication. One patient had superficial wound dehiscence on 10th post-operative day which healed on its own with dressing. One patient developed seroma from 5th postoperative and was managed with dressing and antibiotics and it healed in 2 weeks. None of our patients have developed recurrence and their wounds have healed satisfactorily with minimal scarring and pain. All the patients were able to resume their regular activities within 21 days. All except 2 patients were satisfied with cosmetic outcome. CONCLUSION: The Limberg flap is ideal treatment for pilonidal sinus with minimal postoperative pain, short hospital stay, few complications, rapid return to normal activities, good cosmesis, and a low recurrence rate with short learning curve for young surgeons. Hence, Limberg flap should be routinely used as primary treatment for pilonidal sinus.

680 Peripheral intravascular lithotripsy of ILEO-femoral arteries to facilitate transfemoral TAVI: a multicentric prospective registry

Aims The presence of severe calcific atherosclerosis at the iliofemoral axis may preclude transcatheter aortic valve implantation (TAVI) by transfemoral (TF) approach. Intravascular lithotripsy (IVL) is a novel technology that fractures intimal/medial calcium and increases vessel compliance allowing TF-TAVI in selected patients with peripheral artery disease (PAD). To report on the safety and efficacy of IVL-assisted TF-TAVI in an all-comers population. Methods and results Clinical, imaging and procedural data on all consecutive patients treated by IVL-assisted TF-TAVI in six high-volume European centres (2018–2020) were collected in this prospective, real-world, multicentre registry. IVL-assisted TF-TAVI was performed in 108 patients, increasing from 2.4% to 6.5% of all TAVI in 2018 to 2020, respectively. The target lesion was most often localized at the common and/or external iliac artery (93.5% of cases; average TL-MLD 4.6 ± 0.9 mm with 318 degrees of calcium arc). Transfemoral aortic valve delivery was successful in 100% of cases; final procedural success in 98.2% (two conversion to cardiac open surgery for annular rupture and valve migration). Complications of the IVL-treated segments consisted of one perforation and three major dissections requiring stent implantation (two covered stents and two BMS). Access site related complication included three major bleedings. Three in-hospital deaths were recorded (2.8%, one failed surgical conversion after annular rupture, one cardiac arrest after initial valvuloplasty, one late hyperkalaemia in renal dysfunction). Conclusions IVL-assisted TF-TAVI proved to be a safe and effective approach, which helps expanding the indications for TF-TAVI in patients with severe calcific PAD. Still, these patients maintain a higher than average incidence of peri-procedural complication.